Quality of Care in the Social Services: Research Agenda and Methods
McMillen, J. Curtis, Proctor, Enola K., Megivern, Deborah, Striley, Catherine Woodstock, Cabassa, Leopoldo J., Munson, Michelle R., Dickey, Barbara, Social Work Research
In an era of heightened accountability, remarkably little is known empirically about the quality of social work services. This article applies insights from health services research to propose a research agenda on the quality of care in the social services. The agenda calls for studies that address the definition of quality service, variations in quality, the relationship between quality service and outcomes, structural influences on quality, and ways to improve quality. The article also details specialized research methods for implementing this agenda, including the use of administrative data, risk-adjusted outcomes, case vignettes, standardized consumers, and stakeholder preference assessments. Although social work is currently underrepresented in quality research, social workers' research skills, their traditional academic-agency partnerships, and their accent on consumer experiences position the profession to make quick strides in developing the information needed for quality improvement efforts.
KEY WORDS: quality of care; research agenda; research methods; social services
Assessing and improving quality of care may become this decade s most pressing social work research and practice concern. In nearly every social service sector, stakeholders and contractors expect agencies to monitor and improve quality. Clyman (1999) characterized the shift toward increased accountability in the human services as perhaps "the largest scale social experimentation since the New Deal" (p. 167). Despite the urgent need, social work has yet to engage in the full variety of research endeavors that can inform efforts to improve the quality of social services. This article presents a quality-of-care research agenda for the profession and introduces the field to several specialized research methods that can help implement this agenda.
BUILDING THE CASE FOR QUALITY OF CARE RESEARCH
Quality is not a new concern for social work. At numerous times in our history, the profession placed quality concerns at the top of its agenda. Evidence for this is found in social work's historical emphasis on supervision and lifelong learning, the designation of competence as a core value in NASW's Code of Ethics, development and publication of standards and best practices (for example, Child Welfare League of America, 2000; NASW, 2002), performance assessment requirements (Harry, 1997), and management frameworks such as total quality management (TQM) (Boettcher, 1998).
Despite these emphases, remarkably little is known empirically about the quality of our nation's social services. TQM, as applied, has largely dropped the heavy accent on data collection that was core to its original conceptualization (Hackman & Wageman, 1995). Past social work research efforts aimed at quality improvement have typically focused on outcome evaluations (for example, Hughes, 1999). But knowing what works is only one part of the data needed to create social services agencies that work well. Proctor (2002) noted the dearth of social services research on quality and encouraged the development and application of research methods to quality concerns.
Meanwhile, quality has emerged as the most pressing policy concern in health care (Institute of Medicine, 2001), and a field of research has developed to address quality concerns in the medical services. As part of these efforts, several scholars have attempted to list the main questions that health care quality-of-care researchers address in an attempt to draw boundaries around the field (for example, Brook, McGlynn, & Clearly, 1996; Dickey, Hermann, & Eisen, 1998; Dickey & Sederer, 2001). We used these questions from health services research as a point of departure for building a quality of care research agenda for the social services. These questions rely to some degree on the landmark conceptualization of quality offered by Donabedian (1982), who argued that the structure of a service system affects its service processes and that its service processes affect consumer outcomes. …